Kenya suspends 27 hospitals in US$129 million NHIF Fraud

KENYA—The Health Ministry has suspended twenty-seven (27) hospitals across the country due to allegations of unethical behavior and NHIF fraud.

Apart from finding 27 hospitals culpable of fraud, they were also found persuading patients into unnecessary medical operations, filing bogus NHIF claims, performing multiple eye surgeries without sufficient theatre equipment, and performing falsified surgeries.

This follows an audit done between January and December 2023, during which 27 of the 67 evaluated hospitals were found to be involved in fraudulent operations, resulting in a loss of Sh171 million, according to the health CS.

The Health Cabinet Secretary, Susan Nakhumicha, also stated that the inquiry into the theft found that Sh20 billion (US$128.94 million) may have been lost.

She went on to say that by extrapolating this audit to the overall population of 8,886 hospitals, it is projected that around 3,440 may have engaged in fraudulent activities, potentially resulting in losses surpassing Sh20 billion (US$128.94 million) from approximately 40% of fraudulent hospitals.

The CS added that the facilities used several strategies to commit fraud, including targeting vulnerable people in Nairobi, Meru, Nyahururu, Muranga, Kerugoya, Makueni, Tharaka Nithi, Subukia, Nanyuki, Bungoma, Chuka, and Machakos.

The institutions also coerced people into unnecessary medical treatments, inflicted illness, and, in certain cases, activated dormant health insurance accounts.

The CS stated that the facilities used various techniques to commit fraud, including targeting disadvantaged persons in Nairobi, Meru, Nyahururu, Muranga, Kerugoya, Makueni, Tharaka Nithi, Subukia, Nanyuki, Bungoma, Chuka, and Machakos.

The facilities also persuaded patients into unnecessary medical treatments, created sickness, and in some cases, activated dormant health insurance accounts.

Fictitious documents, falsified claims, and misleading techniques, such as fraudulently indicating members undergoing significant surgery while actively working, have all contributed to the Fund’s defrauding, according to her.

Some hospitals were discovered to target licensed security guards, financially encouraging them to supply biometrics for unlawful purposes.

Anomalies were also detected, according to the CS, including hospitals performing an unusually high number of eye surgeries per day, ranging from 10 to 22, in facilities with a capacity of only two surgeries per day and insufficient theatre capacity.

According to Nakhumicha, such disparities raise serious questions about the veracity of claims and the resources available at these facilities.

The CS stated that under EduAfya insurance, healthcare facilities have been tempting healthy students by offering food incentives for their biometrics, resulting in significant financial losses.

In several incidents, nurses stationed in schools collected fingerprints from non-ill pupils in order to file fake claims, thus exploiting the scheme.

Following this disclosure, Nakhumicha stated that the Authority is dedicated to reducing and eradicating alleged fraud by automating services to minimize human interaction.

She stated that the ICT systems are meant to include robust business intelligence modules that can detect outliers and double payments in real time.

To address this challenge collectively, the government has reaffirmed its commitment to fortifying and protecting the healthcare system’s integrity.

The CS finished by promising the public that the government, in partnership with key stakeholders, will ensure those guilty this heinous deeds are brought to justice.